Valvular Heart Disease Flashcards
(25 cards)
Causes of Aortic Stenosis?
- Supravalvular
- subvalvular
- valvular
-Bicuspid
-rheumatic
-senile degeneration (Tradition risk factros for atherosclerosis (age, smoking, high LDL, HTN); Also seen in CKD
What are 3 classic symptoms of severe Aortic Stenosis?
- syncope
- angina
- exertional dyspnea/ CHF/ decreased funtional capacity
Physical exam findings in severe aortic stenosis?
Systolic murmur
- late peaking = severe
- best heard right upper sternal border
- radiates to the bilateral carotids
- the intensity of the murmur does not correspond to severity
soft or absent S2
pulsus parvus et tardus
best testing for Aortic stenosis?
- Echo- imaging modality of choice
- Cardiac catherterization- only if echo data is not diagnostic
what is the pathophysiology of Aortic stenosis?
- aortic stenosis generally develops gradually leading to LV hypertrophy
- as stenosis progresses, LV filling pressures begin to increase- LV function usually remains normal until late in disease process
- diastolic dysfunction may contribute to symptom onset
Treatment of severe Aortic Stenosis?
- no effective medical therapy for what is a mechanical obstruction
- aortic valve replacement is standard of care
- operative mortality is low in young, healthy patients
- mechanical vs bioprosthetic valves
- TAVR (transcatheter aortic valve replacement)
- prohibitive risk or high risk patients
what are some etiologies of aortic regurgitation that effect the aortic root?
Aortic root
- marfan syndrome
- ehlers-danlos
- syphilis
- hypertension
- coarctation
- dissection (only one that causes acute; everything above causes chronic)
Connective tissue disorders that can strech aortic roots
what are common etiologies that effect the aortic valve in aortic regurgitation?
Aortic valve
- congential bicuspid
- rheumatic
- endocarditis (only one that causes acute; the rest above and below cause chronic)
- prostethic valve dysfunction
- degenerative
- subaortic stenosis
- radiation
- pharmacologic agents
- supracristal VSD
- endocarditis, dissection, trauma
- volume overload is poorly tolerated (LV is not compliant)
- LV diastolic pressure increases rapidly
- often surgical emergency
Acute aortic regurgitation
- slowly progressive LV dilatation with a long asymptomatic period
- ventricle remains compliant
- can accommodate a large regurgitant volume
- maintains near normal diastolic filling pressure
chronic
what would physical exam findings in acute Aortic regurgitation look like?
- Few typical physical exam findings
- murmur may be soft or nonexistant
- manifestations of underlying process predominate
What would physical exam findings in chronic aortic regurgitation look like
- wide pulse pressure
- water hammer pulse- rapidly swelling and falling arterial pulse
- deMussets- sign- head bob with each heart beat
- quincke’s pulses- capillary pulsations in the fingertips or lips
- laterally displaced PMI
- high pitched diastolic murmur at the left sternal border (leaning forward, end-expiration)
- Caused by group A streptococcal pharyngitis
- characterized by an acute febrile ilness 2-4 weeks after an episode of pharyngitis
- before antibiotics–> single largest cause of valvular heart disease
- continues to be common in developing countries
Acute rheumatic fever
what are the major manifestations of acute rheumatic fever?
Major manifestations
- carditis
- polyarthritis
- chorea
- erythema marginatum
- subcutaneous nodules
what are minor manifestations of acute rheumatic fever?
- fever
- arthralgias
- previous rheumatic fever/ rheumatic heart disease
- increased CRP or ESR
- prolonged PR interval on ECG
what is a firm diagnosis of acute rheumatic fever?
- 2 major manifestations or 1 major and 2 minor manifestations AND
- Evidence of a recent streptococcal infection
- diffuse inflammation of the pericardium, epicardium, myocardium, and endocardium
- valve leaflet thickening
- small rows of vegetations (verrucae) on valves
- symptoms: tachycardia, pleuritc chest discomfort
- pericardial friction rub, new or changing murmurs
- Mitral regurg is more common in young pts
- mitral stenosis becomes more common in elderly to mid adults
- heart block on ECG
Carditis
treatment of rheumatic heart disease
antibiotic therapy
- Penicillin (IM penicllin G oner or oral penicillin V for at least 10 days)
secondary prophylaxis (treatment length varies)
- long-term administration of antibiotics to prevent recurrences
- penicillin G administered IM every 3-4 weeks
- almost always caused by rheumatic heart disease
- more than 80 % of patients are women
- clinical presentation often occurs many years after the initial episode of rheumatic fever
Mitral stenosis
clincal presentation of mital stenosis
- dyspnea on exertion
- atrial fibrillation
- low pitched mid-diastolic murmur with opening snap
management of mitral stenosis?
asymptomatic mild mitral stenosis
- conservative therapy
- atrial fibrillation: AV nodal blockers, anticoagulation
Symptomatic severe mitral stenosis
- Percutaneous valvotomy (if valve anatomy is favorable)
- mitral valve replacement
Physical exam: midsystolic click followed by a late apical systolic murmur
complications
- mitral regurgitation
- endocarditis
- arrhythmia
- congestive heart failure
Treatment
* monitoring with Echo and phsycial exam
* severe mitral regurgitation–> timing of surgery depends on symptoms, left ventricular function, left ventricular size
Mitral valve prolapse
Etiology
- Mitral valve prolapse with chordal rupture
- endocarditis with leaflet destruction
- papillary muscle dysfunction or rupture following a myocardial infarction
Clinical presentation
- Tachycardia
- heart failure
- hemodynamic shock
- pulmonary edema on CXR
- murmur may be soft or inaudible
- S3 is often present
- Medical emergency
- urgent surgical intervention is usually indicated
acute mitral regurgitation
Primary regurgitation
- Mitral valve prolapse
- endocarditis
secondary regurgitation
- leaflet tethering or mitral valve annulus dilatation
- consequence of ischemi myocardial dyfunction or dilated cardiomyopathy
Chronic mitral regurgitation
